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0 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />SAN JOAQUIN COUNTY <br />1868 E. Hazelton Ave., Stockton, California 95205 OCT 2 3 2015 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 <br />APPLICATION FOR UNDERGROUND STORAGE TANK <br />RETROFIT OR PIPING REPAIR PERMIT <br />THIS PERMIT EXPIRES 180 DAYS FROM THE APPROVAL DATE. INDICATE PERMIT TYPE BELOW: <br />❑ TANK RETROFIT ❑ PIPING REPAIRIRETROFIT ❑ UDC REPAIR/RETROFIT ❑ COLD START/EVR UPGRADE <br />F <br />EPA Site # <br />Project Contact & Telephone # <br />� <br />Facility NamePhone <br />N �(2_ <br />#20 <br />� <br />Address :5o �9c, k,,n fo k,,S <br />I <br />T <br />Cross Street <br />Y <br />Owner/Operator <br />Phone # <br />cContractor <br />Name <br />Phone # q' 4- Y b0 <br />N <br />T <br />Contractor Address ,Ij% _ �� <br />CA Lic # '/%�o2,i> Class <br />R <br />A <br />Insurer <br />Work Comp # <br />T <br />ICC Technician's Name �t! i `"�'�hk= <br />Expiration Date /0!Z 4,XU1 <br />° <br />R <br />ICC Installer's Name <br />Expiration Date <br />Tank system work area <br />Tank Size <br />Chemicals Stored Currently <br />Date UST <br />Installed <br />(i.e. 87 piping sump, 91 leak detector. UDC 1/2, etc.) <br />T <br />A <br />N <br />K <br />P <br />❑ Approved Approved with conditions ❑ Disapproved <br />L <br />(S a Attachment With Conditions) <br />A <br />NNPlan Reviewers NameOlftte( �:,A �i Date <br />APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN <br />JOAQUIN COUNTY, ENVIRONMENTAL HEALTH DEPARTMENT. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN <br />THE PERFORMANCE OF THE WORK FOR WHICH THIS PER AT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO <br />WORKER'S COMPENSATION LAWS OF CALIFORNIA." RACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY <br />THAT IN THE PERFORMANCE T E WORK FOR H HIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS <br />OF CALIFORNIA." 7 <br />i — �U <br />Applicant's Signature Title /' I, Date <br />or <br />BILLING INFORMATION: <br />Indicate the responsible party to be billed for additional EHD staff time expended beyond permit payment coverage per tank. If <br />the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this <br />responsibility for the billing by signature and date below. �+ <br />NAME &O f�Lti o !fid eG�J� TITLE OW)VII�� PHONE# <br />r_I <br />sic <br />EH <br />2 <br />